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Profile in Oral Health: Is the Standard Prevention Message Working? by Trisha O'Hehir, RDH, MS Hygienetown Editorial Director

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Is the Standard
Prevention Message Working?
by Trisha E. O'Hehir, RDH, MS

Are brushing, flossing and fluoride really preventing dental disease? The evidence suggests that both caries and periodontal disease are completely preventable but despite that fact, these diseases are on the rise. Why isn't the general public capable of preventing dental disease? More importantly, are they even getting the message that dental disease is preventable?

The general public actually thinks tooth decay and gum disease are inevitable. Their parents had cavities and they are convinced they will too. Bleeding gums? Some report to you that their whole family has bleeding gums, yet they aren't concerned about it. To them, it's normal.

Consumers believe you just can't do anything about dental disease. To them, it's inevitable.

In many cases, it does seem inevitable. Despite the best efforts of the dental and dental hygiene professions, dental caries is still the most common childhood disease in the United States today and periodontal disease is still a serious problem.

According to the National Institute of Health (NIH), caries rates declined in the early 1970s, but recent studies show an increase in dental caries. The Centers for Disease Control and Prevention (CDC) reported on data collected between 1988 and 1994 that 24 percent of children two to five years of age had caries in their primary teeth. CDC data reported in 2007 shows that rate had increased to 28 percent. In adults the current data indicate that 92 percent of adults 20 to 64 years of age have experienced dental caries in permanent teeth. In the 1970s it was reported than 50 percent of children up to age 17 were caries free; that's no longer the case.

A 2010 press release from the American Academy of Periodontology reported that partial-mouth probing in epidemiology studies was compared to full-mouth probing and revealed a significant underestimation of periodontal disease - an underestimation of 50 percent! In the study published in the Journal of Dental Research in 2012, new estimates for periodontal disease are much higher than previously reported by NIH. New figures indicate 47 percent of adults 30 years of age and older have at least one tooth with periodontitis. For those 65 and older, the figure is 64 percent. Why isn't modern day prevention working?

There are several aspects contributing to the current situation: education, practice and tradition. Dental and dental hygiene education focus primarily on the treatment of disease, not prevention, so the focus of most research is also on treatment of disease with new technology, materials and approaches in the restorative arena. Dental education focuses on the diagnosis and treatment of dental disease. The four years of dental school generally include a single, one-credit course on prevention. There are bits and pieces of the prevention message sprinkled throughout the curriculum, but grades depend on finding and treating the destruction caused by disease, with little time left for preventing it.

Dental hygiene education places more emphasis on prevention, but the grades and eventually the state board examinations focus on calculus removal. Even dental hygiene education rewards treatment rather than prevention. Clinicians get the message early in their careers that treatment is more valuable to a dental practice than prevention.

In clinical practice, little value is placed on prevention as those procedures are often provided at no charge or simply included with the routine prophylaxis visit. No charge means no value in the minds of the consumer. The value of prevention doesn't translate into actual financial charges for basic preventive information. Educating patients and coaching them on the best ways to prevent caries and periodontal disease are services given away. Time spent providing services at no charge also means a negative impact on the bottom line of the practice. Since prevention is so low on the productivity scale, few clinicians are willing to expend the energy to reflect on the effectiveness of the standard prevention message and implement change where needed. The standard prevention message of brushing, flossing and fluoride has become an established tradition that is no longer questioned. For many decades it has been the message of the ADA. The advice pages on the ADA website for every age group encourage toothbrushing with a fluoride toothpaste and flossing. Two of the highlighted messages on the website are: "Flossing once a day can keep the drill away" and the toothbrushing message "two minutes twice a day." Brushing, flossing and fluoride are still the message despite scientific evidence showing disappointing results from toothbrushing, dental floss and fluoride toothpaste.

Toothbrushing

In a recent systematic review of manual toothbrushing studies published in the International Journal of Dental Hygiene, it was shown that most people can't even remove half the plaque on their teeth with toothbrushing. Researchers reviewed 59 papers with 212 brushing tests involving 10,806 participants to answer the question, "Do we have scientific evidence showing that toothbrushing is effective?" The average amount of plaque removed from pre- to post-testing was 42 percent. Subjects were most often given one minute to brush and told to brush as usual. In a few studies, they were instructed to follow the Modified Bass toothbrushing technique. When separating the data based on the amount of time allowed to brush their teeth, those brushing for one minute only removed 27 percent of the plaque compared to those brushing for two minutes who removed an average of 41 percent of the plaque.

As a clinician, it is assumed that with proper instructions people will actually remove 100 percent of the visible plaque on their teeth. The goal is 100 percent removal, but if not that, at least 85 percent. The evidence that people are only removing 42 percent of the plaque on their teeth is disturbing, but certainly explains why dental disease is still a significant problem. Couple this with information that people rarely brush more than 30 seconds, equating to 27 percent plaque removal and we have a recipe for oral health failure.

Dental Floss

Toothbrushing is the most common approach to mechanical plaque removal despite the fact that caries and periodontal disease are more likely to occur between the teeth than on facial or lingual surfaces.

Dental floss is the first choice for interdental cleaning touted by dentists and hygienists alike. Dental education stresses dental floss for interdental cleaning with such rigor. Many dentists and hygienists continue to recommend dental floss despite noncompliance and scientific evidence showing that few people actually floss daily and that dental floss in the hands of the public does not provide the anticipated bacterial biofilm removal.

A systematic review published in the Journal of Dental Research in 2006 evaluated professional and personal flossing. When daily flossing was performed by an oral health professional, the risk for caries in deciduous teeth was reduced 40 percent. In studies where the subjects reported they performed daily flossing, there was no beneficial effect and no reduction in the risk for caries.

Another systematic review published in 2009 in the International Journal of Dental Hygiene posed the question, "Does flossing plus toothbrushing provide benefit over toothbrushing alone for plaque removal and reduction in gingivitis?" The conclusion was no, flossing does not provide a significant benefit over brushing alone. All the more reason to consider alternatives to dental floss.

Based on these findings, the routine instruction of dental floss use is not supported by scientific evidence. It's better to determine on an individual basis the best approach for cleaning interdental spaces and what alternative to dental floss will work best for each patient. Many different interdental cleaning devices are available that are both effective and easier to use than dental floss, for example sticks, picks and water irrigation. Picking the right interdental cleaning aid depends on the size and shape of the area, morphology of interdental tooth surfaces, dexterity of the patient and willingness to comply with the recommended product. Even if dental floss was effective, which it isn't, compliance is reported to be 13 percent of adults according to a study published in the Journal of Periodontology in 1996 and a Gallop Poll conducted in 1999. The other 87 percent floss infrequently or not at all. It's time for alternatives.

Fluoride

Fluoride toothpaste is the third common recommendation. Toothpaste companies realize that people are not brushing effectively, so their solution is fluoridated toothpaste to deliver a chemical for caries prevention. Toothpaste advertising has been so successful, people now believe the toothpaste is more important than toothbrushing. Based on the current low levels of plaque removal with toothbrushing, that might be true, but fluoride in toothpaste is not achieving the goal of disease prevention either. A recent Cochrane Review evaluated 79 clinical trials evaluating the effect of fluoridated toothpaste in 73,000 children up to age 16. With the U.S. standard 1,000ppm fluoride concentration, the preventive effect was 23 percent. With higher concentrations of prescription fluoride from 2,400ppm to 2,800ppm the preventive benefit increased to 36 percent.

These current findings are quite different from the fluoride toothpaste ads of the 1950s and1960s with children holding a note from the dentist and saying "Look Mom, no cavities." When introduced, it was anticipated that fluoride added to toothpaste would eliminate tooth decay completely, but the evidence proves otherwise.

Summary

With toothbrushing only removing 42 percent of plaque, flossing not adding any benefit while 87 percent don't floss regularly anyway and fluoride toothpaste reducing caries by only 24 percent, it's time for a new science-based prevention message that provides better results. Sticking with this message might be comfortable, but it isn't effectively preventing dental disease. Take a look at your patients and see if the standard prevention message is as ineffective as the research suggests. How healthy are your patients when measuring plaque, gingivitis, bleeding and caries?

Cleaning between the teeth is the most important area to focus on as this is the area at greatest risk for caries and periodontal disease. Knowing that, what is your message to patients about preventing caries and periodontal disease between the teeth? More flossing isn't the answer. We know that won't work. Brushing doesn't reach between the teeth, so that doesn't help. What will your message be?

"Brush, floss and fluoride" has been the message for decades, but it isn't effectively preventing dental disease. It's time for a new message - what will it be? Share your suggestions for a new prevention message in the comments section associated with this article on both Dentaltown.com and Hygienetown.com.

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